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Copyright 2017 American Nephrology Nurses Association
Ball, L.K. (2017). Antegrade vs. retrograde cannulation: Does the evidence support a practice change? Nephrology Nursing Journal, 44(5), 456-457, 464.
Key Words: Hemodialysis adequacy, needle direction in hemodialysis, retrograde cannulation, cannulation, antegrade cannulation.
For the first 50 years of hemodialysis, needle insertion practice was more or less left up to whoever taught you how to cannulate. Hemodialysis staff members indicate they were taught to place the venous needle in the antegrade direction. Arterial needle placement, however, was not so clear cut. Some staff were taught antegrade; others retrograde; and still others were taught that the direction did not matter because the blood pump pulls the blood out of the patient. This information was passed from staff member to staff member, often with the explanation of "this is the way we've always done it." In 1997, the National Kidney Foundation's (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) Vascular Access Guidelines were first published, and were updated in 2000 and 2006. The KDOQI 2006 Update - Guideline 3 indicates that arterial needle placement for the purposes of hemodialysis can be placed either antegrade (with the flow of blood) or retrograde (against the flow of blood) (NKF, 2006). The question to discuss here is: Does the research continue to support this practice of arterial needle placement?
Background
There is a lot of anecdotal (personal) evidence in the renal community about how to perform cannulation for hemodialysis. Unfortunately, there has not been a lot of research to back up what is believed to be best practice. It is important to understand what impact needle direction could have on patient outcomes. Are we concerned about a patient's hemodialysis adequacy? Is needle direction contributing to endothelial damage to the vessel wall and potential early loss of the access? Is there increased recirculation based on needle direction? Let's look at the research and see if it is time to change our current practice.
Evidence
Woodson and Shapiro (1974) were the first to report on needle direction and potential problems with retrograde cannulation. They identified an increased risk of hematoma formation with retrograde cannulation. Because the needle is placed in the direction of the blood flow, as the needle is pulled out, blood is able to...